Basics of Nursing Practice

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1.If the client is allowed to give consent. 2.The client cannot make informed decisions about health care. 3.If the client is permitted to give voluntary consent when parents are not available. 4.The client probably will be unable to choose between alternatives when asked to consent.

1.If the client is allowed to give consent.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection: 1.To the client from outside sources. 2.From the client to others. 3.From the client by using special techniques to destroy infectious fluids and secretions. 4.To the client by using special sterilization techniques for linens and personal items

1.To the client from outside sources.

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP states: 1."I agree; I think you should get a divorce." 2."Everything will be fine, just wait and see." 3."You should be glad that you have such a loving family." 4."In the scheme of things, you do not have a major problem."

2."Everything will be fine, just wait and see."

A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions? 1."You do not need to wear them while you are awake but it is important to wear them at night." 2."You will need to apply them in the morning before you lower your legs from the bed to the floor." 3."If they bother you, you can roll them down to your knees while you are resting or sitting down." 4."You can apply them either in the morning or at bedtime but only after the legs are lowered to the floor."

2."You will need to apply them in the morning before you lower your legs from the bed to the floor."

The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions? 1.Anticipate that nausea and vomiting will continue until the infection is no longer present. 2.The infection causes diarrhea accompanied by flatus and abdominal discomfort. 3.Consume a diet that is high in fiber and low in fat. 4.Other than routine handwashing, it is not necessary to perform special disinfection procedures

2.The infection causes diarrhea accompanied by flatus and abdominal discomfort.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response? 1."You will need to ask your healthcare provider; it is not part of the usual tests for people your age." 2."There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3."It is performed routinely starting at your age as part of an assessment for colon cancer." 4."There must have been a positive finding after a digital rectal examination performed by your healthcare provider."

3."It is performed routinely starting at your age as part of an assessment for colon cancer."

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? 1.Except with rare blood disorders, hemoglobin seldom affects oxygenation status. 2.There are many other factors that impact oxygenation status more than hemoglobin does. 3.A low hemoglobin level causes reduced oxygen-carrying capacity. 4.Hemoglobin reflects the body's clotting ability and may or may not impact oxygenation status

3.A low hemoglobin level causes reduced oxygen-carrying capacity.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1.Trust 2.Growth 3.Belonging 4.Independence

3.Belonging

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? 1.Instruct the client to call for help with elimination needs; answer the client's call light immediately to avoid incontinence. 2.Place a waterproof pad under the client to prevent incontinence and soiling the linens. 3.Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence. 4.Offer toileting to the client every two hours to prevent incontinence.

3.Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? 1.Moving the client's bedside table closer to the bed. 2.Encouraging the client to take an available sedative. 3.Instructing the client to call the nurse before going to the bathroom. 4.Assisting the client to telephone home to say goodnight to the spouse.

3.Instructing the client to call the nurse before going to the bathroom.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? 1.Exempt from any lawsuit because of the doctrine of respondeat superior 2.Totally responsible for the obvious negligence because of failure to report defective equipment 3.Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client 4.Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

3.Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? 1.Counsel the nurse about the problem. 2.Ignore the problem until it happens again. 3.Notify the nurse manager about the problem. 4.Resolve the problem by sending the nurse home

3.Notify the nurse manager about the problem

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action? 1.Use techniques to distract the client. 2.Include the client in decision making. 3.Offer to spend more time with the client. 4.Help the client to problem-solve personal issues

3.Offer to spend more time with the client

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: 1.White blood cell (WBC) count of 8200/mm3 2.Bilateral 3+ pitting pedal edema 3.Oral temperature of 101.3º F 4.Pale skin and nail beds

3.Oral temperature of 101.3º F

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? 1.Increased physical activity 2.Absence of further outbursts 3.Relaxation of tensed muscles 4.Denial of the need for further discussion

3.Relaxation of tensed muscles

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1."The body's fluid needs decrease with age because of tissue changes." 2."Access to fluid may be insufficient to meet the daily needs of the older adult." 3."Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4."The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

4."The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1.Get a full report from the first nurse and adjust the plan accordingly. 2.Ask the health care provider for a report on the client's condition and plan appropriately. 3.Tell the client about the change in staff responsibilities and assess the client's reaction. 4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

Which nursing activities are examples of primary prevention? Select all that apply. 1.Preventing disabilities 2.Correcting dietary deficiencies 3.Establishing goals for rehabilitation 4.Assisting with immunization programs 5.Facilitating a program about smoking cessation

4.Assisting with immunization programs 5.Facilitating a program about smoking cessation

What should a nurse recommend to help a client best during the period immediately after a spouse's death? 1.Crisis counseling 2.Family counseling 3.Marital counseling 4.Bereavement counseling

4.Bereavement counseling

Which action by a home care nurse would be considered an act of euthanasia? 1.Implementing a "do not resuscitate" order in the home health setting. 2.Abiding by the decision of a living will signed by the client's family. 3.Encouraging a client to consult an attorney to document and assign a power of attorney 4.Knowing that a dying client is overmedicating and not acting on this information.

4.Knowing that a dying client is overmedicating and not acting on this information.

The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: 1.Renal function 2.Cardiac output 3.Oxygen saturation 4.Peripheral vascular resistance

4.Peripheral vascular resistance

When permitted by the client, the nurse always should take the time to keep the family informed about what is happening to the client. The purpose of this approach is that informed families will be: 1.able to decrease the client's anxiety. 2.more relaxed when interacting with the client. 3.less likely to cause problems with the nursing staff. 4.better equipped to undertake necessary family role changes

4.better equipped to undertake necessary family role changes

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of Needs does this nursing action address? 1.Safety 2.Self-esteem 3.Physiological 4.Interpersonal

1.Safety

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? 1.Pregnancy 2.Inactivity 3.Aerobic exercise 4.Tight clothing

2.Inactivity

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? 1.Procedures used to implement client care. 2.Sequence of steps used to meet the client's needs. 3.Activities employed to identify a client's problem. 4.Mechanisms applied to determine nursing goals for the client.

2.Sequence of steps used to meet the client's needs.

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.) 1.Gloves 2.Gown 3.Mask 4.Goggles 5.Shoe covers 6.Hair bonnet

1.Gloves 2.Gown 4.Goggles

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on: 1.Alternating sides 2.The right side. 3.The side of the weakness. 4.The side of the client's choice.

2.The right side

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? 1."Do you like living in this country?" 2."When did you come to this country?" 3."Is there a family member who can translate for you?" 4."Which family member do you prefer to receive information?"

4."Which family member do you prefer to receive information?"

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1.Heredity 2.Hypertension 3.Cigarette smoking 4.Diabetes mellitus

1.Heredity

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a licensed practical nurse. What group primarily is protected under the regulations of the practice of nursing? 1.The public 2.Practicing nurses 3.The employing agency 4.People with health problems

1.The public